Shoulder Surgery
Shoulders, elbows, innovation

Platelet Rich Plasma

Repair tissue, heal

Platelet-rich plasma (PRP)

Platelet-rich plasma (PRP) is promoted as an ideal autologous biological blood-derived product that can be exogenously applied to various tissues, where it releases high concentrations of platelet-derived growth factors that enhance wound healing, bone healing, and tendon healing1.

Autologous platelets (taken from the patients own blood) are becoming popular in treating a number of conditions where healing is promoted by the growth factors contained in PRP.

There is however a lack of standardisation in nomenclature, methodology, techniques and evaluation of this emerging technology.

There are conflicting reports in the media, it is claimed to show promise in treating diverse conditions from 'heart attacks' to tennis elbow, but The New York Times also reported Popular Blood Therapy May Not Work. It has also been used along with other procedures to improve outcomes in many different procedures form hair transplantation to tendon/ ligament reconstructions

The aim is to increase the platelet concentration about 5fold from processing venous blood for a potential therapeutic benefit. Commercial 'Kits' are available which simplify the process of extracting PRP from blood. These use centrifuge machines with disposable syringes for the different steps of blood separation to obtain the PRP.

The platelets are rich in a number of growth factors such as TGF-beta, IGF, PDGF, EGF, etc ,and there is evidence to show that different levels of these are produced dependent on the technique for PRP extraction. There is evidence that this promotes healing by promoting cellular repair and regulating scarring.

Shoulder problems

Subacromial impingement results in tendinosis of the rotator cuff tendons from a number of factors. The attempted healing response creates inflammatory tissue, further limiting the available space in the subacromial bursa. There are different treatment options, including non-operative and operative. Patients that do not respond to non-operative treatment options are often treated with subacromial decompression. PRP has been used to augment the results of surgery and to promote quicker healing.

In a randomised controlled study treated patients demonstrated decreased visual analog scales for pain and used significantly less pain medication while gaining an improved range of motion4 for the treated subgroup.

Similarly, PRP has been used after rotator cuff surgery and has shown promise in early work5 . This may be of special value in repairs where the tissue quality is poor, and the 'natural' healing potential is less.

PRP has also been used after shoulder replacements to reduce pain.

Similar techniques have also shown promise in various fractures around the shoulder.

Elbow Problems

Epicondylitis around the elbow is a common problem. This is a degenerative condition (tendinosis) of the tendons and often due to overuse. The micro tears of the tendon substance - the hallmark of the problem -  often do not heal due to conditions  unfavourable for healing in the area. Attempts to help the healing process has been attempted with success with autologous blood injection therapy, and current PRP injection techniques have also shown to be effective6.

A recent double blind randomized study that the use of PRP after 26 weeks and 1 year of follow up has shown a significant difference in decrease of pain and disability of function in favour of the platelet application measured by a Visual Analogue Scale (VAS) and Disabilities of the Arm, Shoulder and Hand score compared to the use of corticosteroids for patients with chronic symptoms of tennis elbow1

Conclusion

Enhancement of tendon healing with autologus growth factors derived from platelet extraction is a promising technique. This carries minimal risk of complications and can be used before surgery is considered or as an adjunct to surgical intervention. However caution needs to exercised in interpreting the evidence due to lack of standardisation of the technique.

References

  1. Positive Effect of an Autologous Platelet Concentrate in Lateral Epicondylitis in a Double-Blind Randomized Controlled Trial - Platelet-Rich Plasma Versus Corticosteroid Injection With a 1-Year Follow-upJoost C. Peerbooms,* MD, Jordi Sluimer,y MD, Danie¨ l J. Bruijn,* PhD, and Taco Gosens,

  2. Heterogeneity of Human Whole Blood Platelet Subpopulations. I. Relationship Between Buoyant Density, Cell Volume, and Ultrastructure; Laurence Corash, Henry Tan, and Harvey R. Gralnick

  3. Platelet rich plasma injection grafts for musculoskeletal injuries: a review Curr Rev Musculoskelet Med DOI 10.1007/s12178-008-9032-5, Steven Sampson, Michael Gerhardt, Bert Mandelbaum

  4. Exogenous application of platelet-leukocyte gel during open subacromial decompression contributes to improved patient outcome. A prospective randomized double-blind study. Eur Surg Res. Everts PA, Devilee RJ, Brown Mahoney C, van Erp A, Oosterbos CJ, Stellenboom M, Knape JT, van Zundert A.

  5. Autologous platelet rich plasma for arthroscopic rotator cuff repair. A pilot study. Disabil Rehabil. Randelli PS, Arrigoni P, Cabitza P, Volpi P, Maffulli N.2008;40(2):203-10. Epub 2007 Nov 12.

  6. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. 2006 Nov;34(11):1774-8. Epub 2006 May 30. Mishra A, Pavelko T.